NCLEX Exam: Nursing Prioritization, Delegation and Assignment 4 — Questions and Answers
Question 1: The high-pressure alarm on a patient’s ventilator goes off. When you enter the room to assess the patient, who has ARDS, the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should you take next?
- Reassure the patient that the ventilator will do the work of breathing for him
- Manually ventilate the patient while assessing possible reasons for the high-pressure alarm (Correct answer)
- Increase the fraction of inspired oxygen on the ventilator to 100% in preparation for endotracheal suctioning
- Insert an oral airway to prevent the patient from biting on the endotracheal tube
Correct answer: Manually ventilate the patient while assessing possible reasons for the high-pressure alarm
A high-pressure alarm on a ventilator, coupled with decreased oxygen saturation and patient distress, indicates an immediate and life-threatening respiratory emergency. The priority is to ensure adequate oxygenation and ventilation without delay. Manually ventilating the patient provides immediate respiratory support, bypassing the malfunctioning ventilator and allowing time to assess and troubleshoot the cause of the alarm.
Question 2: The nursing assistant tells you that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is complaining of nasal passage discomfort. What intervention should you suggest to improve the patient’s comfort for this problem?
- Suggest that the patient’s oxygen be humidified (Correct answer)
- Suggest that a simple face mask be used instead of a nasal cannula
- Suggest that the patient be provided with an extra pillow
- Suggest that the patient sit up in a chair at the bedside
Correct answer: Suggest that the patient’s oxygen be humidified
Oxygen delivered via nasal cannula, especially at higher flow rates like 6 L/min, can be very drying to the mucous membranes of the nasal passages, leading to discomfort and irritation. Humidification adds moisture to the oxygen, which helps prevent this dryness and improves patient comfort. This is a common and effective intervention for this specific problem.
Question 3: The patient with COPD has a nursing diagnosis of Ineffective Breathing Pattern. Which is an appropriate action to delegate to the experienced LPN under your supervision?
- Observe how well the patient performs pursed-lip breathing (Correct answer)
- Plan a nursing care regimen that gradually increases activity intolerance
- Assist the patient with basic activities of daily living
- Consult with the physical therapy department about reconditioning exercises
Correct answer: Observe how well the patient performs pursed-lip breathing
Observing a patient's technique for a learned skill like pursed-lip breathing falls within the scope of practice for an experienced LPN, as it involves data collection and monitoring an established intervention. LPNs are trained to reinforce teaching and assess patient performance of basic nursing skills. Planning comprehensive care, assisting with complex ADLs, or consulting with other departments typically requires the broader assessment and critical thinking skills of a Registered Nurse.
Question 4: The patient with COPD tells the nursing assistant that he did not get his annual flu shot this year and has not had a pneumonia vaccination. You would be sure to instruct the nursing assistant to report which of these?
- Blood pressure of 152/84 mm Hg
- Respiratory rate of 27 breaths/min
- Heart rate of 92 beats/min
- Oral temperature of 101.2 F (38.4C) (Correct answer)
Correct answer: Oral temperature of 101.2 F (38.4C)
A temperature of 101.2 F (38.4C) indicates a fever, which is a significant sign of infection. Patients with COPD are highly susceptible to respiratory infections, and an unvaccinated status further increases this risk. Given the potential for rapid deterioration in COPD patients with infection, this finding requires immediate reporting to the RN for prompt assessment and intervention.
Question 5: To improve respiratory status, which medication should you be prepared to administer to the newborn infant with RDS?
- Theophylline (Theolair, Theochron)
- Surfactant (Exosurf) (Correct answer)
- Dexamethasone (Decadron)
- Albuterol (Proventil)
Correct answer: Surfactant (Exosurf)
Respiratory Distress Syndrome (RDS) in newborns is primarily caused by a deficiency of pulmonary surfactant, which is essential for reducing surface tension in the alveoli and preventing lung collapse. Administering exogenous surfactant directly addresses this physiological deficiency, improving lung compliance and gas exchange. Theophylline and Albuterol are bronchodilators, and Dexamethasone is a steroid, which are not the primary treatment for surfactant deficiency.
Question 6: When a patient with TB is being prepared for discharge, which statement by the patient indicates the need for further teaching?
- “Everyone in my family needs to go and see the doctor for TB testing.”
- “I will continue to take my isoniazid until I am feeling completely well.” (Correct answer)
- “I will cover my mouth and nose when I sneeze or cough and put my used tissues in a plastic bag.”
- “I will change my diet to include more foods rich in iron, protein, and vitamin C.”
Correct answer: “I will continue to take my isoniazid until I am feeling completely well.”
Tuberculosis treatment, including isoniazid, requires a prolonged course, typically 6 to 9 months, to completely eradicate the Mycobacterium tuberculosis bacteria and prevent drug resistance. Stopping medication prematurely, even if the patient feels well, is a common cause of treatment failure and relapse. This statement indicates a critical misunderstanding of the treatment regimen and the importance of adherence.
Question 7: When assessing a 22-year old patient who required emergency surgery and multiple transfusion 3 days ago, you find that the patient looks anxious and has labored respirations at the rate of 38 breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate?
- Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes
- Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs
- Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation
- Switch the patient to a nonrebreather mask at 95% to 100% oxygen and call the physician to discuss the patient’s status (Correct answer)
Correct answer: Switch the patient to a nonrebreather mask at 95% to 100% oxygen and call the physician to discuss the patient’s status
The patient's symptoms (anxiety, labored respirations at 38 breaths/min, and oxygen saturation of 90% despite 6 L/min via nasal cannula) indicate severe respiratory distress and hypoxemia. A nonrebreather mask delivers the highest concentration of oxygen (up to 95-100%), providing the most immediate and aggressive respiratory support. Simultaneously, the physician must be notified for further evaluation and orders, as the patient's condition is critical.
Question 8: Which intervention for a patient with a pulmonary embolus could be delegated to the LPN on your patient care team?
- Evaluating the patient’s complaint of chest pain
- Monitoring laboratory values for changes in oxygenation
- Assessing for symptoms of respiratory failure
- Auscultating the lungs for crackles (Correct answer)
Correct answer: Auscultating the lungs for crackles
Auscultating lung sounds is a fundamental assessment skill that involves listening for specific sounds to gather objective data. This task falls within the scope of practice for an experienced LPN, as it involves data collection and monitoring. Evaluating chest pain, monitoring complex laboratory values, and assessing for symptoms of respiratory failure require a higher level of critical thinking, interpretation, and clinical judgment typically performed by an RN.
Question 9: Which of these medication orders for a patient with a pulmonary embolism is more important to clarify with the prescribing physician before administration?
- Warfarin (Coumadin) 1.0 mg by mouth (PO) (Correct answer)
- Morphine sulfate 2 to 4 mg IV
- Cephalexin (Keflex) 250 mg PO
- Heparin infusion at 900 units/hr
Correct answer: Warfarin (Coumadin) 1.0 mg by mouth (PO)
Warfarin is a potent anticoagulant, and a dose of 1.0 mg is unusually low for therapeutic anticoagulation, especially in a patient with an active pulmonary embolism where rapid and effective anticoagulation is crucial. This dose could be a transcription error or potentially ineffective, making clarification with the prescribing physician essential to ensure patient safety and appropriate treatment for the pulmonary embolus.
Question 10: The patient being looked for by the nurse is thought to be in the beginning stages of dementia. The nurse notes some minor restlessness, short-term memory loss, and confusion. The nurse does a quick mental status examination. Which of the following critical thinking techniques is the nurse utilizing?
- Reasoning
- Validation
- Interpretation (Correct answer)
- Intuition
Correct answer: Interpretation
Interpretation involves making sense of observed data and drawing conclusions about its meaning. The nurse is observing specific signs (minor restlessness, short-term memory loss, confusion) and interpreting these cues as potential indicators of early dementia. This interpretation then prompts the nurse to perform a mental status examination to further validate and assess these findings.
Question 11: A patient has received instructions on how to administer insulin shots on their own. As the patient tries to recap the needle, the nurse notices that more instruction is required. Which nursing critical thinking technique is the nurse using?
- Evaluation
- Interpretation
- Analysis (Correct answer)
- Inference
Correct answer: Analysis
Analysis in critical thinking involves breaking down information into its component parts and examining their relationships to identify patterns or problems. The nurse is observing the patient's technique for administering insulin and specifically identifying an error in recapping the needle. This detailed examination of the patient's actions to pinpoint a specific area needing correction is an example of analysis.
Question 12: Examples of: Case Management, Home Health Care, Physical Therapy
- assessment data
- collaborative interventions (Correct answer)
- dependent nursing interventions
- independent nursing interventions
Correct answer: collaborative interventions
Collaborative interventions are actions that require the expertise and cooperation of multiple healthcare professionals or departments to achieve patient goals. Case Management, Home Health Care, and Physical Therapy are all services provided by other disciplines that the nurse coordinates with, rather than performing independently or as a direct dependent order for a nursing action. They exemplify interdisciplinary teamwork.
Question 13: Utilizing critical thinking abilities during the nursing procedure' assessment phase guarantees that the nurse
- Identifies pertinent nursing diagnoses.
- Intervenes based on patient goals and priorities of care.
- Determines whether outcomes have been achieved.
- Completes a comprehensive database. (Correct answer)
Correct answer: Completes a comprehensive database.
During the assessment phase, critical thinking ensures the nurse systematically and thoroughly gathers all relevant subjective and objective data from various sources. This comprehensive data collection forms the foundation for accurate nursing diagnoses, effective planning, and appropriate interventions. Without a complete database, crucial information might be missed, leading to an incomplete or incorrect care plan.
Question 14: An illustration of a quantifiable objective is:
- "The patient will be able to lift an acceptable amount of weight by week one."
- "The patient will be able to lift 10 lb by October 19th 1500." (Correct answer)
- "The patient will be able to lift weights by October 19th 1500 ."
- "The patient will be able to lift his normal weight amount."
Correct answer: "The patient will be able to lift 10 lb by October 19th 1500."
A quantifiable objective must be specific, measurable, achievable, relevant, and time-bound (SMART). Option B clearly states a specific, measurable weight (10 lb) and a precise date and time (October 19th 1500) for achievement. This level of detail allows for objective evaluation of the patient's progress, unlike the other options which are vague or lack specific metrics.
Question 15: Which of the following claims qualifies as objective data? (Check every box that applies.)
- "I'm short of breath."
- "I feel weak all over when I exert myself."
- "Lung sounds clear bilaterally, diminished in right lower lobe." (Correct answer)
- "My pain level is down to 2. It was 8."
- "Blood pressure 90/68, apical pulse 102, skin pale and moist." (Correct answer)
Correct answer: "Lung sounds clear bilaterally, diminished in right lower lobe."
Objective data are measurable and observable facts that can be perceived by the nurse through their senses or with instruments. 'Lung sounds clear bilaterally, diminished in right lower lobe' and 'Blood pressure 90/68, apical pulse 102, skin pale and moist' are both direct observations and measurements made by the nurse. The other options are subjective statements reported by the patient.
Question 16: Using Maslow's hierarchy of demands, the nurse decides what medical attention a client with diabetes mellitus requires first. Which need is considered to be the client's top priority?
- The client joins the local American Diabetes Association support group.
- The client attends classes to deal with body image after amputation of the right leg.
- The nurse teaches the client proper home safety techniques to prevent diabetic wounds.
- The nurse teaches the client how to properly change dressings on the​ right-leg amputation site. (Correct answer)
Correct answer: The nurse teaches the client how to properly change dressings on the​ right-leg amputation site.
According to Maslow's Hierarchy of Needs, physiological needs are the most basic and highest priority. Proper dressing changes for an amputation site are critical to prevent infection, promote healing, and maintain skin integrity, directly addressing a physiological need. Addressing this immediate physical need takes precedence over safety education, body image concerns, or social support groups.
NCLEX Exam: Nursing Prioritization, Delegation and Assignment 4
The high-pressure alarm on a patient’s ventilator goes off.
When you enter the room to assess the patient, who has ARDS, the oxygen saturation monitor reads 87% and the patient is struggling to sit up.
Which action should you take next?